17 Million People, 5 Months, and a 90-Day Install: The Medicaid Math Nobody's Doing
By Jill Steeley, founder of Steeley Strategic Solutions and host of the Community Health Collective podcast. I'm a former FQHC CEO - I inherited an $800,000 deficit at what's now PureView Health Center in Helena, Montana, and turned it around. I write for the person sitting in the chair I used to sit in.
What You'll Get From This Piece:
The three HR1 changes, in plain English, with the dates that actually matter
Why churn is a bigger threat to your revenue than ineligibility
The one message you have to send patients before you send them a single reminder
Why three HR1 changes require three different messages, not one blast
What automated patient outreach actually costs in staff hours versus what it saves
How Rural Health Transformation Program funding can pay for the technology
What implementation really looks like, and why 90 to 120 days should scare you a little right now
Most of the patients you're about to lose are still going to qualify for Medicaid.
Sit with that for a second, because it changes what you should be doing about it.
We are not primarily facing an eligibility crisis. We're facing an administrative one. Starting January 1, 2027, Medicaid expansion adults ages 19 to 64 go through redetermination every six months instead of every twelve. Twice the deadlines. Twice the paperwork. Twice the chances that a letter goes to an old address, a form gets filed late, or somebody just doesn't see it.
Projections run between 11 and 17 million people losing coverage. For comparison, when the public health emergency unwound, roughly 4 million people lost Medicaid. That was awful, and it was also a single event with a beginning and an end. This one doesn't end. It's Groundhog Day, twice a year, indefinitely.
When Medicaid is 35 to 60% of your operating revenue, that's not a policy story. That's your budget.
I recorded an episode of the Community Health Collective with Alison Williams about what to actually do about it. Alison spent about 10 years inside a community health center in Upstate New York, another decade leading the national FQHC customer success team at Athena Health, was a HRSA grant reviewer as a hobby (her word), and now runs her own consulting firm and works with Vital Interaction. She's seen this from inside a health center, inside a vendor, and from the grant reviewer's side of the table.
Here's what we worked through.
What exactly is changing with Medicaid under HR1?
Three things, on two dates.
October 1, 2026 - immigrant eligibility narrows. Federally funded Medicaid and CHIP get limited to lawful permanent residents, Cuban and Haitian entrants, and COFA nationals. Refugees, asylees, TPS holders, humanitarian parolees, and trafficking and domestic violence survivors lose eligibility. These are people who have been legally covered for years. Emergency Medicaid remains.
January 1, 2027 - six-month redeterminations. For expansion adults 19 to 64, with renewals scheduled on or after that date. The clock runs from the date each patient got Medicaid, patient by patient. There is no single deadline you can put on a wall calendar. Every patient has their own.
January 1, 2027 - work and community engagement requirements. Eighty hours a month of work, training, education, or community service, verified at application and at renewal. And here's the piece that lands on you: managed care plans are legally barred from determining or assisting with work-requirement compliance. They can't help. Your patient has to document it themselves - or you help them.
Why is churn worse for my health center than ineligibility?
Because ineligibility is a loss you can plan for. Churn is a loss that happens on a random Tuesday and shows up as a denied claim six weeks later.
When a patient falls off Medicaid and comes back on three months later, you don't just lose three months of revenue. You lose it in ways that keep costing you:
1. The visits during the gap get written off or billed to a sliding fee, and you don't collect the PPS rate.
2. Their benefit package can change when they re-enroll, which affects what's covered and what you're paid.
3. The look-back window is shrinking. Retroactive coverage for expansion adults tightens to one month starting January 1, 2027, so the safety net that used to catch some of this is going away at the exact moment you need it more.
4. Your staff eats the rework - re-enrolling somebody you already enrolled, chasing documentation you already collected, appealing denials that shouldn't exist.
Every one of those costs is avoidable if the patient never falls off in the first place. That's why I keep saying it: your enrollment team is now a retention team.
What's actually going wrong when we try to remind patients ourselves?
1. The reminders go out during business hours. Your enrollment coordinator calls between 9 and 5. Your patients are at work between 9 and 5. That's the whole failure right there.
2. The list lives in a spreadsheet. Somebody pulls it, marks it up, and re-pulls it. It's stale the day after it's built, and it doesn't know who already scheduled.
3. The state's letter doesn't get opened. Either it goes to an address the patient moved away from, or it looks like every other piece of government mail.
4. Your text gets marked as spam. Unbranded number, no context, nobody saved you as a contact. It never gets read.
5. One message goes to everybody. A patient with a redetermination in September, a patient who needs to document 80 work hours, and a patient losing eligibility entirely all need completely different information. A mass blast serves none of them.
6. The job burns people out. Alison told me about a health center where one woman's entire job was calling patients all day, for about two years. She eventually said, and I'm quoting the health center's CEO here, "I don't care what you buy. I am out." She left. After they put automated outreach in place, they never replaced the position. That's not a story about technology replacing a person. That's a story about a job nobody should have had.
How do we do proactive patient outreach at scale without hiring a department?
This is the question every CEO asks me, usually phrased as "Jill, I have one enrollment person." Fair. Here's the answer we got into in the episode.
1. Earn the inbox before you use it. This is the step almost everyone skips. Before any reminder goes out, one message goes out that says, in effect, "Hi, this is Friendly Family Health Center. Please add us as a contact." All of your phone numbers get sorted and linked to your logo, so every message from that point forward arrives branded and recognized instead of looking like spam. Vital Interaction also gives health centers QR codes to post at the front desk, in exam rooms, and at checkout so patients can add the contact right there during a visit. Do this first. Everything downstream depends on it.
2. Build smart lists instead of spreadsheets. The platform sits as an overlay on top of what you already have - your EMR, your practice management system - ingests the data, and builds dynamic lists. Eligibility end dates. Diabetes diagnoses with no visit since March. Patients who canceled versus patients who no-showed, because those two people deserve different messages. The list updates itself.
3. Send from a face patients already trust. Patients do what their providers tell them. They do it far more reliably than when the front desk asks. So one provider records a simple two-minute video with a script, and AI turns that into many personalized videos - by condition, by visit reason, by campaign. If you have one location and one beloved doctor, that's your person. If you have twelve locations, Alison's advice was to find the one provider, nurse, or care manager the community knows, respects, and trusts, and start there. Nothing goes out without provider approval.
4. Write three campaigns, not one. Retention outreach for patients who'll stay eligible. Work-hour documentation support for patients facing the 80-hour requirement. Sliding fee outreach for patients losing eligibility October 1. Three audiences, three calls to action, three tones.
5. Start early and stay specific. Reach out about 120 days ahead. Confirm the address. Tell them exactly which documents they'll need to produce, because these are not people with a tidy folder on a desk. Then tell them where to go for help - your enrollment team, or the community partner who helped them last time and speaks their language.
6. Make it two-way and multilingual. Vital Interaction supports two-way texting with real translation in the loop. Your staff member types in English, the patient reads it in Spanish, replies in Spanish, and it comes back to your staff in English. Well more than a handful of languages are supported, and more can be added based on your population.
8. Dial the persistence up and down. One health center Alison works with runs a 3-day, 5-day, 10-day, and 25-day follow-up sequence. The important part is what happens when the patient schedules: the system sees the appointment and drops them off the list. No 10-day nag. No 25-day nag. You can turn up the pestering, and you can turn it down, and the system knows when to stop.
9. Keep the humans for the human work. Nobody is arguing for taking the person out of patient care. The argument is that the repetitive, soul-draining, low-yield tasks should move off your staff's plate so they can spend their time on the patients who genuinely need a person to talk to.
What about the patients who really are losing coverage on October 1?
I asked Alison this directly, because I wanted to know where a communication platform stops being the answer.
She was straight about it. First, this is a board conversation and a frontline operations conversation before it's a technology conversation. Size the population. Understand who they are and how they're documented in your system. Then use targeted outreach for what it's actually good for: making sure every one of those patients knows your sliding fee discount program exists, how to apply, what a visit will cost them on the slide, and who to talk to.
That is not a PPS payment. It's not going to fix your revenue. But those patients are already frightened - of immigration enforcement, of the last year generally, and now of losing their coverage. Health centers have been the trusted place for 60 years. Proactive, compassionate, honest outreach that doesn't overpromise is worth doing even when the reimbursement math doesn't work.
How do we pay for this?
Two ways, and they stack.
The revenue you retain. When you keep one patient enrolled in Medicaid and collect the PPS rate on their visit, that starts paying for the technology immediately. Run your own numbers on how many retained patients it takes to cover the annual cost. For most centers the number is smaller than you'd guess.
Rural Health Transformation Program funding. This is the move I'd want you to take away from this article. Patient engagement technology maps directly onto RHTP's stated priorities - IT modernization, chronic disease management, population health, interoperability. If you're eligible and you're building an RHTP proposal, write the implementation and the first year of the software into it. Consider writing in the second year too, so you're not staring at a new line item when the funding sunsets. Talk to your state agency, your primary care association, and your state Office of Rural Health, whatever yours is called.
I say this because I know how the safety net thinks about technology spending. We're scared of big investments. And listen, I get it - I sat in that chair with an $800,000 deficit. But the cost of not adopting this is now higher than the cost of adopting it.
What does implementation actually take?
Ninety to 120 days after you sign, depending on your platform and integrations. Vital Interaction has integrated with over 40 different systems, and if the data lives somewhere accessible through an API or HL7, they can generally get to it. Occasionally that means going to your EMR vendor and asking them to release fields you're entitled to as a customer. You are allowed to ask for your own data.
But the timeline isn't the hard part. The hard part is who's at the table. Alison was emphatic about a triangle:
1. An executive sponsor who says out loud, "We're doing this, and we're all in."
2. Operational owners - the people who actually care about no-shows, cancellations, and care gaps, and who talk to patients every day.
3. IT, from the beginning, not as an afterthought.
She's watched health centers do this and succeed. She's watched health centers skip it, and in her words, it becomes a struggle bus - not unsalvageable, just harder and slower than it needed to be.
You also need one clear answer to "what's the imperative?" No-shows? Care gaps? Medicaid retention? Converting urgent care patients into established patients? Pick the thing. Health centers can run as many campaigns as they want and prioritize them over time, but you start with one.
Why do we need to act now?
It's August. Redeterminations and work requirements begin January 1. Implementation takes three to four months.
If you sign in September, you go live around December, and you're ready. If you start thinking about it in November, you're implementing a Medicaid retention system in the middle of your first six-month redetermination cycle.
I'd rather you be early.
What should we do next?
If you want the numbers before the vendor call, start there. I built a free HR1 planning worksheet that lets you run your actual patient counts and payer mix and see what HR1 does to your bottom line under a moderate and a severe scenario. Email me at [email protected] with "HR1 plan" in the subject line and I'll send it to you.
If you want to see the platform, Vital Interaction is at www.vitalinteraction.com, and my clients get 33% off through this link: https://guidance.vitalinteraction.com/jill-steeley. You can also reach Alison Williams directly at [email protected] or on LinkedIn at linkedin.com/in/alison-a-williams.
If you want the full conversation, listen to the episode. And if you want the broader HR1 picture, episodes 35 and 36 go deep on the coverage cliff and on recovering revenue through retroactive Medicaid. They're all at www.jillsteeley.com/podcast.
And if you're a health center executive who's tired of figuring this out alone, my FQHC CEO Connect Bootcamp opens for its next cohort in September.
You're not doing this alone.
About the Author
Jill Steeley is the host of the Community Health Collective Podcast and an executive coach to leaders across community health centers, FQHCs, and mission-driven healthcare organizations. After two decades inside the healthcare leadership world and close to 250 healthcare leaders coached and mentored, she helps healthcare executives build the leadership skills they were never formally taught - and helps full leadership teams shift culture together rather than one leader at a time.
Learn more at jillsteeley.com.
